Sexual dysfunctions: a therapist's manual

1. The programme at a glance

Indication. Sexual dysfunction in an adult — desire, arousal, erection, ejaculation, orgasm, genito-pelvic pain or difficulty with penetration — that has lasted several months and causes suffering, once the medical assessment has been done or set in motion. In a person on their own or in a couple, whatever the sexual orientation.

Reference model. A sex therapy of cognitive and behavioural orientation: the sensate focus of Masters and Johnson (1970), times of touching with no aim described in section 31; the cognitive interference model of Barlow (1986), in which anxiety turns attention towards the cues of failure (section 5); the circular model of the sexual response of Basson (2000), in which desire may come in response rather than come first (section 6); mindfulness-based approaches; and graded exposure for difficulties with penetration (section 36).

Format. Twelve 60-minute sessions, 75 when both partners are present, weekly up to session 6 and then fortnightly, because the work is done between the sessions. Two booster sessions, at one month and at three months.

Mechanism targeted. Taking sexuality out of the register of the test. Whatever its origin, a dysfunction is most often maintained by the monitoring of one's own response, by the anticipation of failure or of pain, and by avoidance. Treatment suspends the demand, brings attention back to sensations, and lifts avoidance step by step.

Session	Focus	Session output
1	Welcome and assess	Request clarified, safety checked, medical assessment organised
2	The sexual history	Trigger and maintaining factors identified
3	Understanding	Circle written down, aims without performance
4	Suspending the demand	Pause accepted, first touching times fixed
5	Touching with no aim	Exercises done, obstacles identified
6	Leaving the spectator role	Attention brought back to sensations
7	What we tell ourselves	Core beliefs re-rated
8	Talking to each other	One conversation prepared and held
9	The module, first step	Genital step, progression written down
10	The module, moving on	Predictions tested
11	Resuming without demand	Repertoire widened, failure prepared for
12	Review and relapse prevention	Written plan, measures repeated

In this table, the circle is the diagram of the factors that maintain the difficulty (section 5). The pause suspends, for a few weeks, penetration and any attempt to go "all the way" (session 4). The genital step widens touching to the genital areas, still with no aim (session 9). The core beliefs are the two or three sentences the person tells themselves about their difficulty, whose credibility is rated from 0 to 100; re-rating them means giving them a new rating in order to measure change (section 12).

What the person takes away. Eight printable worksheets, listed in section 41: my record, my circle, a few landmarks, touching with no aim, what I tell myself, talking to each other, my exercises step by step, my plan for what comes next.

What sets this programme apart from the other manuals on this site. The medical assessment, which comes before any exercise. The refusal to make penetration the criterion of success, which changes what is aimed at and what is measured. And a two-storey protocol — a common core, then one module per dysfunction — which says, at each storey, what research establishes.

2. Before you start

The five decisions to make first

Has the medical assessment been done? Section 8. An erectile disorder can be an early sign of cardiovascular disease, pain on penetration can come from a vulval condition that can be treated, low desire can be the effect of an antidepressant. The exercises do not begin without knowing.

Is there violence or coercion now? Section 11. A relationship in which one is afraid of the other, in which one forces or is forced, is an indication neither for sex therapy nor for couple therapy.

Has there been sexual violence in the past? Frequent and rarely disclosed, it changes the way the exercises are run. Section 11.

Individual or couple? Section 14. Working with a person on their own is not a second-best substitute for working with a couple.

And what is being asked for? The request often comes from someone else — the partner, a doctor. Desire that is weaker than a partner's is not, in itself, a dysfunction.

What this programme does not treat

Minors. A situation in which a minor is exposed to violence comes under child protection.

Compulsive sexual behaviour, the paraphilias and gender incongruence as such, which call for other forms of care. A transgender person who presents with a dysfunction does, on the other hand, come under this programme, with the adaptations of section 38.

A mainly organic cause, whose medical treatment it accompanies without replacing it.

A relationship in crisis. When conflict, a recent infidelity or the question of separation dominates, the sexual difficulty is treated afterwards, or within a couple therapy — see Couple therapy: a therapist's manual.

Post-traumatic stress disorder after sexual violence, which is treated first, with Post-traumatic stress disorder in adults: a therapist's manual.

How to use it

Read the whole text before the first session, in particular sections 6, 8, 11 and 31, then the module for the dysfunction concerned — sections 32 to 36 — before session 3. Every session follows the same frame: the aim, the steps, what you say, the common errors, and the criterion for moving on.

Two warnings specific to this presenting problem.

Everything happens outside the consulting room. You see nothing, you touch nothing, you observe nothing. The exercises are described, prepared, carried out in private and debriefed. This frame is not negotiable, and it protects the person as much as it protects you.

And the therapist's embarrassment is a limiting factor. If, by the end of session 2, you do not know what actually happens during a time of intimacy, the formulation will be wrong.

3. Four situations not to confuse

1. A variation or a passing difficulty

What you observe. An erection that fails on a tired evening, desire that is lower during a period of stress, an orgasm that does not always come.

What points to it. Its brevity, its link with a context, the absence of lasting distress. In a large British survey, about four men in ten and one woman in two who had been sexually active in the past year reported at least one difficulty lasting three months or more, but only about one person in ten described themselves as distressed about their sex life (Mitchell et al., 2013).

What that implies. Information and permission — the first two levels of the PLISSIT model, whose acronym stands for four increasingly specialised levels of intervention: permission, limited information, specific suggestions, intensive therapy (Annon, 1976). Permission consists in telling the person that what they are experiencing or wish for is common and legitimate; limited information, in giving them the precise facts that answer their question. That is enough here, with no twelve-session programme.

2. A sexual dysfunction

What you observe. A difficulty that comes back most of the time, for several months, that causes suffering, and around which an avoidance has organised itself.

What that implies. The programme described here, once the medical assessment has been done or set in motion.

3. A difficulty that is mainly medical or drug-related

What you observe. A gradual onset in a person who has vascular risk factors, an onset that follows a new treatment, a pain that is localised and reproducible, a difficulty present in every situation, including alone.

What that implies. Medical treatment first or alongside. The programme often remains useful, because an organic cause frequently brings on a performance anxiety that may outlive it.

4. A difficulty that expresses the relationship or a constraint

What you observe. Desire that is absent with this partner and present elsewhere, a pain that exists only within one relationship, an avoidance that protects against something.

What that implies. Section 11 if coercion is suspected, a couple therapy if conflict dominates. Treating the symptom while ignoring what it protects is a mistake, and sometimes a wrong.

And one situation that is not a difficulty

Asexuality. A person who defines themselves as asexual does not, on that ground alone, have a dysfunction: for desire disorders, DSM-5-TR sets the diagnosis aside when an absence of desire that has been there from the start is better explained by that identity. If they do consult, it is often about a couple issue, which is treated as such.

The three sorting questions

"What happens, concretely, and since when?" It dates the onset and obliges the person to describe.

"Is it the same in every situation — alone, with someone else, at other times?" It distinguishes a generalised difficulty, present in every situation, from a situational difficulty, limited to one partner or to certain times: it is the most useful clue for pointing towards an organic component or towards a psychological or relational one.

"And what does it do to you?" It separates the person's own distress from the request of those around them.

4. The dysfunctions, one by one

Low desire

What you observe. Few or no sexual thoughts, little wish to initiate, often a reduced receptivity. In women, difficulties of desire and of arousal very often go together.

What needs clarifying. Spontaneous desire, which arises without stimulation, and responsive desire, which appears in response to a situation or to a contact. In many women in long relationships, desire is mainly responsive (Basson, 2000): this is not a dysfunction, and confusing it with a disorder is a mistake.

What misleads. The gap in desire between partners. About a quarter of people who had been in a couple for at least a year reported an imbalance of interest in sex in the British survey (Mitchell et al., 2013): it is a difference, not a disorder in the one who desires less.

Arousal disorders

What you observe. An arousal experienced as weak, reduced genital sensations, insufficient lubrication, despite a stimulation that ought to be enough. Experienced arousal and the genital response do not always coincide, and distraction by thoughts unrelated to the situation contributes substantially to the difficulties of the sexual response, in women as in men (Brotto et al., 2016).

Erectile disorder

What you observe. A marked difficulty in obtaining or maintaining an erection that is sufficient, or a clear fall in rigidity.

What needs clarifying. Nocturnal or morning erections, or satisfactory erections when alone, whose preservation points towards a psychological component without excluding an organic one. And the onset, sudden and situational or gradual and generalised. This is the dysfunction where the medical assessment is most often decisive, and where performance anxiety is the most constant.

Premature ejaculation

What you observe. An ejaculation that is very rapid after the beginning of penetration or of stimulation, before the person wishes it, with the feeling of not being able to delay it, and a distress.

What needs clarifying. The form that has been there from the start, and the acquired form. In the definition of the International Society for Sexual Medicine, the first is recognised by a very short latency, about one minute at most after the beginning of vaginal penetration, present from the earliest experiences and on almost every occasion; the second, by a clear shortening of a latency that had been usual until then, often falling to about three minutes or less. The acquired form calls for a targeted medical examination, looking in particular for an erectile disorder, a thyroid disorder or an inflammation of the prostate, and psychological or relational factors may set it off or maintain it (Althof et al., 2014). And expectations about duration: when they are unrealistic, precise information settles part of the request.

Delayed ejaculation

What you observe. A marked delay, a rarity or an absence of ejaculation with a partner, when it often remains possible alone. One looks for medication, serotonergic antidepressants first of all, neurological conditions, diabetes, pelvic surgery, and very particular habits of solitary stimulation.

Female orgasmic disorder

What you observe. An orgasm that is absent, much delayed or markedly less intense, in most situations.

What needs clarifying. Whether orgasm has ever been reached, alone or with a partner, and with what stimulation. The absence of orgasm from vaginal penetration alone is the situation of a large proportion of women, not a dysfunction, and the diagnosis does not apply when the difficulty comes from insufficient stimulation.

Genito-pelvic pain and difficulties with penetration

What you observe. A difficulty or an impossibility of vaginal penetration, including for a tampon or an examination; pain during attempts; a marked fear of that pain; an involuntary contraction of the pelvic floor. Any one of these is enough.

What needs clarifying. The form, there from the start or acquired — often after an infection, a birth, surgery or the menopause — and the site. Pain at the entrance to the vagina, triggered by contact, often comes from a provoked vestibulodynia, the most frequent form of chronic vulval pain (Morin et al., 2021). This picture brings together vaginismus, in which contraction and fear make penetration difficult or impossible, and dyspareunia, pain during intercourse, because the pain, the fear and the contraction maintain one another.

Substance- or medication-induced dysfunction

What you observe. A difficulty that begins with a treatment, a change of dose, a withdrawal or a consumption. On antidepressants it is frequent, varies a great deal from one molecule to another, and remains very under-reported if the question is not asked (Serretti and Chiesa, 2009). Section 15.

5. What maintains the difficulties

Whatever the origin — organic, psychological, relational, or all three — three mechanisms maintain most dysfunctions. Treatment targets all three of them.

Performance anxiety

Sexuality becomes an examination. The question is no longer "what am I feeling?" but "is it going to work?". Erection, arousal, orgasm, duration or the absence of pain become expected results, and the expectation is enough to compromise them.

Self-monitoring

Masters and Johnson (1970) described the spectator role: during sexual activity, the person watches themselves instead of feeling. They check their erection, watch out for the pain, assess their arousal, scan the other's face. Barlow (1986) placed this cognitive interference at the heart of the problem: in people who have a dysfunction, anxiety directs attention towards the cues of failure, which reduces arousal and confirms the failure; in others, a comparable activation does not have that effect. What makes the difference is not anxiety itself, but what it does to attention.

Avoidance

It locks the circle. Intercourse is avoided, then the gestures that might lead to it, then tenderness itself, because every contact has become an implicit demand. Talking about it is avoided too, including with the doctor. No experience comes to contradict the prediction any more, and the partner reads the avoidance as a rejection.

The full circle

The circle starts from a failure, a pain or an embarrassment, whether or not they have an organic cause. The person then anticipates the next one, and, during intimacy, their attention turns towards monitoring. The response diminishes, or the pain increases, which confirms the fear and leads to avoidance. Between the two partners, a misunderstanding also sets in: one feels rejected, the other feels summoned. This is the diagram you draw in session 3.

The circle of pain

Pain makes pain feared. Fear produces a contraction of the pelvic floor and a fall in arousal and in lubrication, which increase the next pain. Catastrophic beliefs — "it is going to tear me", "I am made differently" — harden, and avoidance sets in. In women who had never been able to have penetration, the improvement obtained through exposure works in particular through the fall in those beliefs (ter Kuile et al., 2015).

What prepares the ground

The history often reveals an upbringing that presented sexuality as dangerous or shameful, difficult first experiences, sexual violence, a negative body image, poor knowledge, unrealistic expectations. These factors explain a vulnerability; it is the maintaining mechanisms that are treated.

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